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Region 8 Midyear Regional MeetingStockton, CA

October 12-14, 2018

Proposed Resolutions

Proposing APhA-ASP ChapterPolicy Numb

er

Page Numb

erCalifornia Health Sciences University (CHSU) R8.1 2California Northstate University R8.2 3Chapman University School R8.3 4Keck Graduate Institute (KGI) R8.4 6Loma Linda University R8.5 7Midwestern University Glendale R8.6 9Regis University R8.7 11Roseman University Henderson R8.8 13Touro University California R8.9 14University of Arizona R8.10 15University of Colorado R8.11 17University of Hawai`i at Hilo R8.12 18University of New Mexico R8.13 20University of California, San Diego (UCSD) R8.14 22University of California, San Francisco (UCSF) R8.15 24University of the Pacific (UOP) R8.16 27University of Southern California (USC) R8.17 29West Coast University R8.18 31Western University of Health Sciences R8.19 33

APhA Academy of Student Pharmacists Region 8 Midyear Regional Meeting 2018

R8.1

Proposing APhA-ASP Chapter: California Health Sciences University

Proposed Resolution Title/Topic: Lowering cost of prescriptions

Proposed wording: APhA-ASP encourages incentivizing low-cost methods such as implementation of coupon machines in low-income communities to help pay for a portion of the prescribed medications to combat nonadherence.

Background Statement:Adherence issues arise for several reasons and we would like to promote a system of supporting patients financially so nonadherence is not a result. Patients are unable to stay on their medication regimen due to high cost of the medication prescribed, inability to afford insurance to pay for the medication, or the insurance doesn’t cover the medication.

References:https://www.nacds.org/news/the-cost-of-medication-non-adherence/https://www.cdc.gov/mmwr/volumes/66/wr/mm6645a2.htmhttps://www.nacds.org/news/the-cost-of-medication-non-adherence/

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes ___ No_X__

If yes, please provide the number and title of the adopted resolution(s) as well as your rationale for the addition of this Proposed Resolution:

Author of Proposed Resolution: Michael Riel

Author Phone Number: (559) 575-4363

Author Email Address: [email protected]

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R8.2

Proposing APhA-ASP Chapter:California Northstate University

Proposed Resolution Title/Topic: Establishing Daily Verification Limits

Proposed wording: APhA-ASP supports the implementation of daily limits on the number of medications that a single pharmacist can verify.

Background Statement:

Excessive daily verifications has become a problem for pharmacists in recent years, especially with the rise of mail-order pharmacy services. Establishing reasonable limits ensures that the proper time and attention is given to each medication that a pharmacist verifies and promotes patient safety. These limits should be data-driven and dependent on the type of pharmacy. This idea is not without precedent, as a bill titled “Pharmacy – Prescription Limits” was introduced to the Illinois General Assembly in February of 2017.

Pros:● Increases the amount of time that a pharmacist is able to spend verifying each

medication and helps further ensure patient safety.● Increases the demand for pharmacists as companies would need to hire more

pharmacists to fill the same volume of prescriptions.

Cons:● There is the possibility of increased prescription drug prices for patients.

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes __ No__X_


Author of Proposed Resolution: Kyle Bakkie



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R8.3

Proposing APhA-ASP Chapter: Chapman University

Proposed Resolution Title/Topic: APhA-ASP shall support a new patient care project on mental health.

Proposed wording: APhA-ASP encourages pharmacists and student pharmacists to actively participate in education and patient care related to mental health.


1. Mental health is a growing field in which pharmacists and student pharmacists can contribute.

• Depression is a common illness worldwide, with more than 300 million people affected, however less than half of people affected in the world receive effective treatments (in many countries, fewer than10%) [1]. Countries across the world have seen an increase of mental illness and are trying to takeaction with issues with professional resources, available facilities, and economic burden [2]. There aremany different types of stigma linked to mental health, such as stigma in receiving mental health careand personal shame in seeking help. Mental health stigma in any form has been shown to hinderthose who need help with mental health care [3].

• Community-based pharmacists are health care professionals that are most accessible to the public. Pharmacists can help in screening for depression because they are the most accessible health care professionals. Research has shown that trained pharmacists may be equipped with skills and knowledge to screen and identify consumers with mental illness [4]. Community-based pharmacists can be the link to referring patients to different healthcare professionals. A study was performed by Wang et. al, where the inclusion of a psychiatric pharmacist in a community health center. This study showed how essential the psychiatric pharmacist was to act as a link between different areas of care (i.e. specialty care, social security, psychotherapy) [5].

2. Mental health care often involves medications and monitoring.• Pharmacists can provide skills, knowledge, and attitudes to other health care

professionals within an interprofessional environment. Pharmacists can detect and resolve or prevent drug related problems,which can help with the safety and efficacy with medication use. Pharmacists can provide comprehensive drug information to patients and other health care

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professionals. Pharmacists can advocate medication adherence, primary prevention, health promotion, and lifestyle modification activities in the community [4].

3. Mental health awareness and education is necessary and can be expanded upon by pharmacists andstudent pharmacists.

• Pharmacists may increase medication adherence with a psychiatric patient population by providingeducation about medications and their use in a group setting instead of individually. In a pharmacist led group setting, in addition to the pharmacist sharing knowledge, the patients are able to share their experiences with others who may be in similar situations, which is better received than the experiences being shared by someone perceived to be in an authority position [6].

• As patients have reported stigma as a major barrier in their treatment and recovery, pharmacists and student pharmacists may play a role in educating the general public, students, their colleagues, and other health care professionals to help reduce mental health stigma. It is important to remember that patients with mental health conditions are humans first, just as are patients with physical health conditions, and recognizing this humanity is important to providing better care for these patients [7].

References1. http://www.who.int/news-room/fact-sheets/detail/depression2. Shah, A., & Beinecke, R. (2009). Global Mental Health Needs, Services, Barriers, and Challenges.International Journal of Mental Health, 38(1), 14-29. Retrieved from http://www.jstor.org/stable/413452713. Clement S., Schauman O., Graham T., Maggioni F., Evans-Lacko S., Bezborodovs N., Morgan C., Ru ̈sch N.,Brown J.S.L., Thornicroft G. What is the impact of mental health-related stigma on help-seeking? Asystematic review of quantitative and qualitative studies. Psychol Med. 2014 doi: 10.1017/S00332917140001294. Rubio-Valera, M., Chen, T. F., & O’Reilly, C. L. (2014). New Roles for Pharmacists in Community MentalHealth Care: A Narrative Review. International Journal of Environmental Research and Public Health,11(10), 10967–10990. http://doi.org/10.3390/ijerph1110109675. Wang I., Dopheide J.A., Gregerson P. Role of a psychiatric pharmacist in a Los Angeles “Skid-Row” safetynet clinic. J. Urban. Health. 2011;88:718–723. doi: 10.1007/s11524-011-9573-6.6. Norman S., Davis E., and Goldstone L.W. (2012) Impact of pharmacist-led or Co-led Medication Education Groups on Patient Outcomes: A Literature Review. Mental Health Clinician: October 2012, Vol. 2, No. 4, pp. 86-90.

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7. D’Arrigo, T., “Challenging Stigma in Mental Health Care: The Power of Compassion in Your Community.” Pharmacy Today. June 2017. Volume 23, Issue 6, Pages 32–35. <https://www.pharmacytoday.org/article/S1042-0991(17)30751-X/fulltext#>

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes _X_ No___

If yes, please provide the number and title of the adopted resolution(s) as well as your rationale for the addition of this Proposed Resolution:2017.3 Efforts to Reduce Mental Health StigmaRationale: This proposed resolution will expand on the existing resolution to encourage student pharmacists to take a more active role in seeking, creating, and participating in education and patient care related to mental health.

Author of Proposed Resolution: Marleyna Daughters and Brittany Nguyen

Author Phone Number: (949)-613-4020

Author Email Address: [email protected], [email protected]

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R8.4

Proposing APhA-ASP Chapter:Keck Graduate Institute

Proposed Resolution Title/Topic:Shared Liability for Pharmacy Law Violations.

Proposed wording:APhA-ASP supports sharing of liability between pharmacists and ancillary staff who contributed to violation in pharmacy laws or practices.

Background Statement: Pros:

o Shared liability would promote greater ownership and care for actions made by ancillary staff.

o More pharmacists would potentially be interested in taking on pharmacist-in-charge roles, since the burden of liability would be spread.

Cons:

o An increase in liability taken on by the ancillary staff could result in a demand in higher pay.

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes ___ No_X_


Author of Proposed Resolution: Daniel Sah



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R8.5

Proposing APhA-ASP Chapter: Loma Linda University

Proposed Resolution Title/Topic: Pharmacy Technician Training in Immunization.

Proposed wording: 1. APhA-ASP supports pharmacists delegating administration of immunizations by a

certified pharmacy technician who has completed the ACPE-accredited immunization course.

2. APhA-ASP encourages the expansion of Standing Order Programs to include pharmacy technicians who have completed the ACPE-accredited immunization course.

Background Statement:Standing Order Programs allow patients to be vaccinated by non-physician healthcare personnel, such as nurses, midwives, physician assistants, and pharmacists. Medical assistants can also give various injections and intramuscular vaccinations to patients, whereas pharmacy technicians are prohibited by law from administering immunizations to patients.

Currently, Idaho is the only state that allows pharmacists to delegate the task of immunization to pharmacy technicians who have completed the immunization course certified by the Accreditation Council for Pharmacy Education (ACPE). Screening the patients, providing consultation, and all clinical aspects of the immunizations are still the responsibility of the pharmacists. The pharmacy technicians would perform the technical task of administering the immunization. Data from Idaho shows that this new implementation has been successful, with 953 immunizations given by pharmacy technicians and zero adverse reactions reported.

According to the executive director of Idaho state board of pharmacy, Dr. Alex Adams, pharmacists use their professional judgment every day in the workplace; therefore, they should be able to use their professional judgment to delegate this technical task of immunization to qualified technicians. When technicians are empowered to use their skills at the highest level, pharmacists can have more time to focus on their scope of practice, which is also expanding.

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Pros: If pharmacy technicians can administer immunization throughout the United States, an expansion similarly to the expansion of pharmacists administering immunizations in 2009, this could have the potential to increase the workflow of the pharmacy. If this is implemented, it could decrease patient wait time in the pharmacy. Furthermore, this would increase immunization rates towards the goal of 80% implied by Healthy People 2020. This could have strong implications in promoting public health.

Cons: This option might only be good for technicians who have worked in the profession for many years (10+). Pharmacy technicians might want an increased salary for their increased responsibilities; this might not fit in the company’s budget.

References:1. Adams, Alex. Expanded Certified Pharmacy Technician Roles. The Idaho State

Board of Pharmacy News. 2017 March;37(3):1 (https://nabp.pharmacy/wp-content/uploads/2016/06/ID032017.pdf)

2. APhAASP. Off Script Episode 4: Changes in Idaho. Youtube. August 9, 2018. 16:19 (https://www.youtube.com/watch?v=PWRgltOEKK4&feature=youtu.be)

3. California Code of Regulations (CCR) Title 16, §§ 1366‐1366.4, 1366.31‐1366.334. Healthy People 2020. Immunization and infectious disease

(www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases)

5. Isenor, J. Edwards, N., Alia T., Slayter, K., MacDougall D., McNeil S., Bowles S. Impact of Pharmacists As Immunizers On Vaccination Rates: A Systemic Review and Meta-Analysis. Vaccine. 2016 Nov 11;34(47):5708-5723. (https://doi.org/10.1016/j.vaccine.2016.08.085)

6. McKeirnan, K., Frazier, K., Nguyen, M., Garrelts MacLean L. Training pharmacy technicians to administer immunizations. Journal of the American Pharmacists Association. 2018;58(2):174-178. (https://doi.org/10.1016/j.japh.2018.01.003)

7. Stewart, A. M., Lindley, M. C., & Cox, M. A. State Law and Standing Orders for Immunization Services. American Journal of Preventive Medicine. 2016;50(5),133-142. http://doi.org/10.1016/j.amepre.2015.10.003

8. Weaver, Krystalyn. Pharmacist-Administered Immunizations: What Does Your State Allow? Pharmacy Today. 2015. http://www.pharmacytoday.org/article/S1042-0991(15)30130-4/pdf

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes ___ No_X


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http://www.pharmacytoday.org/article/S1042-0991(15)30130-4/pdf

http://www.pharmacytoday.org/article/S1042-0991(15)30130-4/pdf

http://doi.org/10.1016/j.amepre.2015.10.003

https://doi.org/10.1016/j.japh.2018.01.003

https://doi.org/10.1016/j.vaccine.2016.08.085

https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases

https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases

https://nabp.pharmacy/wp-content/uploads/2016/06/ID032017.pdf


Author of Proposed Resolution: Jenee Vo



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R8.6

Proposing APhA-ASP Chapter: Midwestern University Glendale

Proposed Resolution Title/Topic:Require that a clinical indication (e.g. diagnosis, problem or therapeutic objective) be present on prescription orders and all the indication be placed on the pharmacy dispensing labels at the discretion of the patient.

Proposed wording: APhA-ASP encourages legislation mandating that a clinical indication or its equivalent such as a diagnosis, problem or therapeutic objective be required on all prescription orders and provide patients with the option to have this information included on their pharmacy dispensing labels to enhance patient understanding of, and adherence to, their medications and improve pharmacists’ ability to make more informed clinical decisions.


From the patient perspective, the option to include an indication on prescription labels will increase adherence and understanding of their medical condition that is requiring medical intervention. Many patients, especially those on multiple medications, may get confused as to which of their medications are for what disease state. This is especially true in the growing elderly population. Although patients are given package inserts every time they pick up a new or recurrent prescription, many do not want to take the time to utilize and read through these documents. By ensuring patients know what each drug is for in a straightforward and concise manner, there is the potential for a positive trend in patient knowledge regarding their medication regimen. This small improvement will not only increase adherence, it will also positively impact patient’s knowledge for their medication and improves that patient’s knowledge on their disease. This may stress the importance of why that medication is needed and the potential risks if doses are missed or if the drug is taken inappropriately.

From the perspective of the pharmacist, requiring an indication on prescription labels will help decipher what counseling points are necessary and pertinent to deliver since many medications are approved for multiple uses. It can be helpful to determine whether the drug is complimentary to other current therapies they are on. All too often patients bring in prescriptions and forget what their provider wrote it for. Pharmacists are legally obligated to assess the safety and appropriateness of prescribed medication therapy, unfortunately, some do not have the opportunity to have immediate access to pertinent clinical information that may be essential in proper medication therapy management.1 Research has supported that providing pharmacists with access to the clinical indication improves the quality of pharmacists clinical decisions and is more time efficient by preventing unnecessary prescriber

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contacts to clarify orders.2,3 It is necessary for a pharmacist to know understand the therapeutic objective to advise the patient appropriately. To bypass confusion and frustration, this is a simple fix.

An opposition to this is that providing an indication may infringe upon the rights of HIPAA. This addition to the label does not violate privacy laws due to the patient giving permission to make known their personal health information (PHI) on their labeling.

In order to implement this addition to the label, it can easily be put in as part of the sig coding for any retail pharmacy company. For example, the sig can be written for a patient taking a calcium channel blocker as “Take one tablet by mouth daily for hypertension (high blood pressure)”. This addition is simple, efficient and should take little to no extra computer programming effort.

1. Rupp MT. “The Pharmacist’s Role in Off-label Prescribing” Arch Intern Med, April 12, 2010;170:652. Warholak-Juarez T, Rupp MT, Salazar T and Foster S. “The Effect of Patient Information on the Quality of Pharmacists’ Drug Use Review Decisions” J Am Pharm Assoc 2000;40:500-8.

3. Warholak TL, Rupp MT, Leal S, et al. “Assessing the effect of providing a pharmacist with patient diagnosis on electronic prescription orders” Research in Soc & Admin Pharm 2014;10:246-51.

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes _X__ No___


1997.9 - Inclusion of Disease State/Intended Use on PrescriptionsAPhA-ASP shall support a position of prescription reform to include the indication for use/disease state of the prescribed medication, possibly in coded format (e.g., ICD-9 format), on all prescriptions in order to allow the pharmacist or student pharmacist to provide more effective patient care.

Although this resolution addresses adding an indication to prescriptions, it does not discuss adding the indication to the dispensing labels. This is a prospective supplement that needs to be looked farther into.

Author of Proposed Resolution: Alexis Hayes


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R8.7

Proposing APhA-ASP Chapter: Regis University

Proposed Resolution Title/Topic:Universal Electronic Health Record

Proposed wording:APhA-ASP supports the develop and implementation of a secure universal or standardized electronic health record. The electronic health record should be voluntary and easily assessable to all relevant healthcare stakeholders to ensure continuity of care for patients. The electronic health record should include, but not be limited to patient’s medical history, physical examinations, medication list, medication fill history, allergies, insurance information (if applicable), and informed consent form.

Background Statement:The U.S. Department of Health and Human Services (HHS) has been promoting the advancement of a health information infrastructure that increases the connectivity of electronic health information and interoperability of health information technology among the healthcare industry. Pharmacists are fully capable key healthcare stakeholders in providing quality healthcare services.

Pharmacists have played a vital role in expanding comprehensive medication therapy management (MTM) to increase patient outcomes, create efficiency, and reduce health care costs. Pharmacists often face gaps in patient’s medical health information when identifying drug therapy problems. Access to a universal electronic health record would provide additional health information to fill those gaps in comprehensive medication therapy.

Utilization of multiple pharmacies and the ability to self-pay with coupon cards allow for gaps in medication filling history among different pharmacist. This has clear impacts on medication adherence and identification of drug-drug interactions. Access to filling history from a universal electronic health record would provide better transparency and communication to improve healthcare services.

Security and protection of personal health care information is a serious issue. Data breach and unauthorized access to personal electronic health information must be prevented with any potential threats eliminated. References:

https://www.pharmacytimes.com/publications/health-system-edition/2015/september2015/access-to-a-health-systems-electronic-medical-record

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“Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. (2015). ONC. Retrieved July 30, 2018 from http://www.healthit.gov/sites/default/files/ ONC_2015_nationwide-interoperability-roadmap-final-version-1.0.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4115075/

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes ___ No__X_


Author of Proposed Resolution: Rommel Fontanilla



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R8.8

Proposing APhA-ASP Chapter: Roseman University Henderson

Proposed Resolution Title/Topic:Expedited Communication between Pharmacists and Prescribers

Proposed wording: 1. APhA-ASP encourages the implementation of efficient systems that expedite

communication between pharmacy staff and prescribers.2. APhA-ASP encourages hospitals, clinics, and other health systems to train their

staff on how to redirect inquiries from the pharmacy to the proper channels.

Background Statement:There are several reasons why pharmacists would call a prescriber upon receiving a prescription. These inquiries can range from a simple clarification to a more complex dialogue involving alternatives to therapy or intervention to prevent adverse events. Unfortunately, these calls to the prescribers often involve long wait times and multiple call transfers. Making a call to the prescriber can often disrupt the pharmacy’s work flow and slow down its operations. It affects the patients who are not able to receive the correct medications in a timely manner. By improving the lines of communication between pharmacists and prescribers, we can improve medication safety, pharmacy work flow, and patient satisfaction.



Author of Proposed Resolution: Alec Madriaga



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R8.9

Proposing APhA-ASP Chapter:Touro University California

Proposed Resolution Title/Topic: Mental health program development

Proposed wording: APhA-ASP strongly encourages the development of a depression awareness training and burnout identification program for students, faculty and practitioners at each campus or facility.

Background Statement:Over the recent years, suicide rates in the population have been rising,

increasing 30% from 13.2 per 100,000 persons in 1999 to 19.2 per 100,000.1 As one of the most commonly seen healthcare providers, pharmacists are in a unique position to notice changes in patients as they come in to pick up prescriptions or check in on their medications. Initiating the dialogue and understanding the signs relating to depression can encourage the patient to be more aware of mental status changes and talk to their primary care providers.

In addition, pharmacists themselves are also susceptible to burnout and depression. A study in Japan showed that hospital pharmacists have a high level of psychological distress and burnout.2 By incorporating training and identification programming into the pharmacist toolbelt, practitioners are better able to serve themselves, their colleagues and their patients by being more aware of the warning signs.

References:1. https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?

s_cid=mm6722a1_w&quot2. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3208-5

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes __X_ No___


2017.3 - Efforts to Reduce Mental Health StigmaThe addition of this proposed resolution would provide a call to action to develop an implementable program to improve mental health and reduce stigma.

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https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3208-5

https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_cid=mm6722a1_w&quot

https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_cid=mm6722a1_w&quot


Author of Proposed Resolution: Leslie Wu



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R8.10

Proposing APhA-ASP Chapter: University of Arizona

Proposed Resolution Title/Topic:PBM Transparency

Proposed wording:APhA-ASP encourages accessible Pharmacy Benefit Manager transparency concerning pricing structures, rebates, reimbursement and medication billing, and placing a limit on the profit a PBM can make from prescription drug discounts.

Background Statement:In an analysis published this June on the performance of PBMs in Ohio, Medicaid paid $223.7 million more than pharmacies for medications, and the difference was kept as profit by PBMs. Earlier this year, the Arkansas Insurance Department fined CVS Caremark and placed on them a one-year probation for 454 violations of reimbursement claims and 38 violations of inaccurate information. Though CVS Caremark statements dispute the claims of unfair practice, little more has been revealed publicly to shed light on the matter. Several other states have recently dealt with similar reimbursement issues. While it is difficult to come to a definite conclusion, the matter would be cleared up if price and contract information were readily available.

Pharmacy Benefit Managers (PBMs) were initially created to negotiate drug prices between health plans and pharmaceutical companies to afford patients the best value. If the negotiated profits are going entirely to the PBMs, their role in medication pricing is strictly for profit, with no benefit going to pharmacy or patient. Poor patient adherence is one of the largest cost burdens to the current healthcare system, and the increasing cost of prescription medications is a major factor in poor medication adherence. A review published in 2012 indicated non-adherence is responsible for approximately 125,000 deaths, 10% of hospitalizations, and a cost on the U.S. healthcare system of $100 to $289 billion every year. Sixty-two percent of pharmacists surveyed in 2,400 CVS pharmacies believe cost is the number one reason for non-adherence. In a 2017 Truven Health Analytics-NPR Health Poll of 3,003 patients, cost was a primary reason many patients did not pick up, refill, or continue to take their medications. Making sure cost savings are primarily to the benefit of the patient would save patients money, improve adherence, and come full circle to reduce the overall cost of healthcare.

For small pharmacies, roughly 1 out of 5 prescription fills are reimbursed at a rate lower than the purchase price. Allowing the odds to be stacked against small businesses does disservice to both business and the patient. As the largest health care companies have recently become increasingly powerful through vertical integration, or

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the merging of non-competitive businesses, it is of utmost importance to make sure regulations are in place to prioritize patients and patient outcomes.

https://www.ajmc.com/newsroom/ohio-tells-medicaid-pbms-that-2019-will-be-a-time-for-transparent-contracts

http://ci.uky.edu/kentuckyhealthnews/2018/07/11/state-fines-caremark-top-pharmacy-benefit-manager-1-5-million-for-violations-including-inaccurate-and-inconsistent-information/

http://annals.org/aim/fullarticle/1357338/interventions-improve-adherence-self-administered-medications-chronic-diseases-united-states

http://truvenhealth.com/Portals/0/Assets/TRU_18156_0617_NPR_Poll_Prescription_Drugs_FINAL.pdf



Author of Proposed Resolution: Thomas Goss



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R8.11

Proposing APhA-ASP Chapter: University of Colorado

Proposed Resolution Title/Topic: Pharmacist Burnout

Proposed wording: APhA-ASP encourages development and implementation of programs targeted at preventing provider burnout within the pharmacy profession.

Background Statement:Burnout within the healthcare realm is nothing new, however, most of the studies to this point has been focused on physicians and nurses. The level of stress and the workload on pharmacists is comparable to that of other health professions and in many places is continually increasing due to expanding roles of pharmacists. Addressing burnout is not only important for job satisfaction, but also for the quality of care patients are receiving. For example, poor provider well-being and moderate-to-high levels of burnout are associated with poorer patient safety outcomes and increased medical errors. Because of these implications, further development of strategies for avoiding and minimizing burnout is necessary, as is integration of those strategies into pharmacy training programs. It is important that pharmacy practitioners and trainees are aware of work practices that can contribute to burnout, recognize burnout syndrome, and understand the influence it has on patient safety and healthcare quality.

Patrick J. Bridgeman, Mary Barna Bridgeman, Joseph Barone. Burnout syndrome among healthcare professionals. American Journal of Health-System Pharmacy Feb 2018, 75 (3) 147-152; DOI: 10.2146/ajhp170460



Author of Proposed Resolution: Kelli Rourke



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R8.12

Proposing APhA-ASP Chapter: University of Hawai`i at Hilo

Proposed Resolution Title/Topic: Tuberculosis Testing and Assessment

Proposed wording: APhA-ASP recommends granting pharmacists the prescriptive authority to administer and assess tuberculin skin tests (TSTs). Assuming the preceding is fulfilled, appropriate education and training should be incorporated into the curricula of all colleges of pharmacy nationwide.

Background Statement:Tuberculosis (TB) is second only to HIV/AIDs as the greatest killer worldwide resulting from a single infectious agent. It is estimated that one-third of the world’s population has latent TB. The Centers for Disease Control estimates that (in the United States) upwards of 11 million people have latent TB. A TST is the most commonly used method of screening for latent tuberculosis in the United States. Pharmacists are eligible to administer the TST, however many do not have the proper training or the prescriptive authority to do so. Several states have already passed legislative measures allowing pharmacists to prescribe and assess a TST. As it stands, there are only a limited number of states (including Washington, Idaho, and New Mexico) that allow pharmacists to prescribe, assess, and interpret the results of a TST1.

APhA-ASP would like to spearhead the efforts in providing prescriptive authority to pharmacist to prescribe and assess TST nationwide. APhA-ASP should request involvement from the Board of Pharmacy in order to issue protocols and trainings that enable pharmacist to administer and evaluate TSTs. TST education and training should also be incorporated into the curricula of all colleges of pharmacy.

Currently, nurses and physicians are the only healthcare providers able to prescribe and assess TSTs, nationally. Pharmacies have access to a wide spectrum of patients, allowing for more direct access to care without requiring appointments. Enabling pharmacists to provide TSTs will lessen the burden on other medical providers. Increasing accessibility to TSTs and emphasizing public knowledge of TB will encourage community members to receive appropriate screening, resulting in a decrease in cumulative incidence of TB. Just as pharmacists are now able to immunize, they are also willing and capable of providing TSTs.

Reference:McKennon, Skye A., and Jennifer Arnold. “Student Pharmacists as Tuberculosis Screeners.” American Journal of Pharmaceutical Education 80.2 (2016): 24. PMC . Web. 11 Oct. 2018.

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Author of Proposed Resolution: Kathleen Nguyen, Brandi Chun, Karen Pae, Ryan McMillan

Author Phone Number: Kathleen (720-227-2496), Brandi (808-349-8017), Karen (808-277-5957), Ryan (772-696-0706)

Author Email Address: Kathleen ([email protected]), Brandi ([email protected]), Karen ([email protected]) , Ryan ([email protected])

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R8.13

Proposing APhA-ASP Chapter: University of New Mexico

Proposed Resolution Title/Topic:Expanded Pharmacy Technician Duties

Proposed wording: 1. APhA-ASP encourages all state boards of pharmacy to allow expansion of

pharmacy technician duties to include receipt of new verbal prescription orders and transfer of prescriptions.

2. APhA-ASP supports the implementation of advanced pharmacy technician training by the employer and/or pharmacy technician certification programs to ensure proficient knowledge of brand vs. generic names, drug indications, and usual dosing that would allow them to perform such duties safely and competently.

Background Statement:Expansion of the pharmacy technician role to include receipt of new prescriptions and ability to transfer prescriptions to or from another pharmacy would allow the pharmacist-in-charge more time to focus on clinical duties and patient safety. Increased technician training and responsibility is more beneficial now than ever before, as the duties of the pharmacist continue to expand and the list of drugs on the market continues to grow. The pharmacy technician shall receive additional training to ensure competency in brand vs. generic names, drug indications, and usual dosing, to appropriately record new and transferred prescriptions. This additional fluency would also have the potential to catch any wrong drug errors during prescription pick-up. Many times, the pharmacy technician is the only pharmacy employee the patient has contact with and verifying the drug and indication with the patient is the last line of defense against mis-filled prescriptions.

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes __X_ No___


2002.11 – encourages state boards of pharmacy to require employers to train technicians expand training to include competencies required to safely obtain verbal prescription orders and prescription transfers.

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2002.3 – prevents technicians from counseling technicians should not counsel; however, knowing and communicating the indication to the patient has the potential to catch wrong drug errors. Any questions that arise at this point would be addressed to the pharmacist.

Author of Proposed Resolution: Adriana Carrillo



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R8.14

Proposing APhA-ASP Chapter: University of California, San Diego

Proposed Resolution Title/Topic:Controlled Substance Diversion Prevention Program within Inpatient Health Care Facilities

Proposed wording: APhA-ASP supports the robust implementation of controlled substance diversion prevention programs within health systems to identify medication diversion, correct areas of non-compliance, and protect patient safety.

Background Statement:Drug diversion occurs frequently in the outpatient setting due to the public’s

ability to easily access prescription medication, but a more discrete form of drug diversion occurs in inpatient health care facility workplaces. The common drugs diverted from health care facilities are opioids and other high value drugs such as antiretroviral drugs, athletic performance-enhancing drugs, and nonopioid psychotropic drugs. Drug diversion often occurs in health care facilities for financial gain or for personal use (often when a health care worker is addicted to the diverted drug). In the outpatient setting, there is a set system of checks and balances before a medication is dispensed, but in health care facility environments, it is easier for a single provider to engage in drug diversion from central stores or during drug preparation, drug administration, and/or disposal of drug waste. As a result of inpatient drug diversion, patient safety can be compromised on a large scale; between 2000 and 2014, the Centers for Disease Control and Prevention recorded four outbreaks of hepatitis C virus infections due to health care personnel tampering with syringes or vials containing fentanyl, affecting 84 patients in total.

It is crucial for health systems to implement a robust controlled substance diversion prevention program compliant with federal and state laws and regulations to protect patients, employees, the health system, and the general public. The ASHP Guidelines on Preventing Diversion of Controlled Substances states that controlled substance diversion prevention programs should build in tight control through a process of checks and balances, diligent surveillance, and prompt intervention in order to prevent, promptly identify, and investigate suspected diversion. Drug auditing applications can help create clear policies, procedures, and lines of accountability for dealing with such investigations and reporting in a timely and thorough manner. All these goals can be met by involving pharmacists, pharmacy technicians, anesthesiologists, nurses, and leadership. Therefore, APhA-ASP should support the robust implementation of controlled substance diversion prevention programs within health systems to identify medication diversion, correct areas of non-compliance, and protect patient safety.

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References

Berge KH, Dillon KR, Sikkink KM, Taylor TK, Lanier WL. Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention. Mayo Clinic Proceedings 2012;87:674-82. doi https://doi.org/10.1016/j.mayocp.2012.03.013

Brummond PW, Chen DF, Churchill WW, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health Syst Pharm 2017;74:325-48. Epub 2017/01/06. doi 10.2146/ajhp160919

Schaefer MK, Perz JF. Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel. Mayo Clinic Proceedings 2014;89:878-87. doi https://doi.org/10.1016/j.mayocp.2014.04.007



Author of Proposed Resolution: Claire Chen



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R8.15

Proposing APhA-ASP Chapter: University of California, San Francisco

Proposed Resolution Title/Topic: Medicinal Use of Cannabidiol

Proposed wording: APhA-ASP supports the use of cannabidiol in pediatric patients suffering from severe seizure disorders (i.e. Lennox-Gastaut Syndrome and Dravet Syndrome) given sufficient clinical evidence showing a favorable benefit-risk profile.

Background Statement:Though medicinal use of active marijuana components (i.e. cannabidiol) remain

culturally controversial and legally complex, promising research has been published1,2

specifically for its therapeutic use in pediatric patients, ages 2 years and above, suffering from severe seizure disorders such as Lennox-Gastaut Syndrome (LGS) and Dravet Syndrome (DS). Cannabidiol oil solution (CBD-OS) was used in the treatment of LGS and DS for seizure reduction in pediatric patients. Two studies 1,2 were done by GW Research which demonstrated statistically and clinically significant outcomes in seizure reduction as well as predictable, manageable, and tolerable side effects6 (i.e. decrease in appetite, diarrhea, and drowsiness). No worsening of seizures was observed with use of CBD-OS in these early studies.6

Despite the current status of cannabis as a Schedule 1 drug, cannabidiol can and should be used in patients progressing in LGS and DS without improvement with conventional treatment. Patients who do not respond well to standard treatment are higher risk of mortality and morbidity due to persistent seizures despite usage of multiple anti-epileptic drugs (AEDs) 6. The FDA has stated concern about potential false advertising about CBD use for serious conditions outside of LGS and DS without scientific evidence.7 However, the FDA has stated their commitment to pursuing rigorous scientific study upon the efficacy and safety of marijuana-based products prior to market release. Further research is still necessary, but given current clinical evidence, it is sufficient to not delay treatment for patients at risk of diminishing quality of life and function.

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes _X_ No___

If yes, please provide the number and title of the adopted resolution(s) as well as your rationale for the addition of this Proposed Resolution:2015

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1. APhA supports regulatory changes to further facilitate clinical research related to the clinical efficacy and safety associated with the use of cannabis and its various components.

2. APhA encourages health care provider education related to the clinical efficacy, safety, and management of patients using cannabis and its various components.

3. APhA advocates that the pharmacist collects and document information in the pharmacy patient profile about patient use of cannabis and its various components and provide appropriate patient counseling.

4. APhA supports pharmacist participation in furnishing cannabis and its various components when scientific data support the legitimate medical use of the products and delivery mechanisms, and federal, state, or territory laws or regulations permit pharmacists to furnish them.

5. APhA opposes pharmacist involvement in furnishing cannabis and its various components for recreational use.

Medicinal Use of Marijuana19801. APhA supports research by properly qualified investigators operating under the investigational new drug (IND) process to explore fully the potential medicinal uses of marijuana and its constituents or derivatives.

2. APhA opposes state by state, marijuana specific, or other drug specific legislation intended to circumvent the federal laws and regulations pertaining to (a) marketing approval of new drugs based on demonstrated safety and efficacy, or; (b) control restrictions relating to those substances having a recognized hazard of abuse.

References:

1. “A Study to Investigate the Efficacy and Safety of Cannbidiol (GWP42003-P; CBD) as Adjunctive Treatment for Seizures Associated with Lennox-Gastaut Syndrome in Children and Adults (GWPCARE4)” (updated 2018)

https://clinicaltrials.gov/ct2/show/NCT02224690?term=cannabidiol&recrs=e&fund=2

2. “Antiepileptic Efficacy Study of GWP42003-P in Children and Young Adults With Dravet Syndrome” (updated 2018)


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3. “FDA panel recommends CBD for pediatric seizure disorders” (2018)

https://www.mdedge.com/clinicalneurologynews/article/163796/epilepsy-seizures/fda-panel-recommends-cbd-pediatric-seizure

4. “Parent on Behalf of Student v. Rincon Valley Union Elementary School District” (2018)

https://www.documentcloud.org/documents/4928752-BrookeAdamsDecision.html

5. “Santa Rosa Family Wins Fight for Daughter to Go to School – With Her Cannabis Meds” (2018)

https://www.kqed.org/news/11693703/santa-rosa-family-wins-fight-for-daughter-to-go-to-school-with-her-cannabis-meds

6. “CBD-OS for the Treatment of Lennox-Gastaut Syndrome and Dravet Syndrome” (2018)

https://www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials/drugs/peripheralandcentralnervoussystemdrugsadvisorycommittee/ucm604738.pdf

7. “Statement by FDA Commissioner Scott Gottlieb, M.D. on the importance of conduction proper research to prove safe and effective medical uses for the active chemicals in marijuana and its components” (2018)

https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm611047.htm

Author of Proposed Resolution: Henry Huang

Author Phone Number: (626)-378-3398


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R8.16

Proposing APhA-ASP Chapter:University of the Pacific

Proposed Resolution Title/Topic: Prescription State Monitoring Program Student Pharmacy Access

Proposed wording:APhA-ASP encourages that current state PDMP’s allow student pharmacist registration and access to complete intern work that may require review of controlled medications for patient care.

Background Statement:Currently, California Board of Pharmacy requires all state licensed pharmacist

and California-licensed prescribers with DEA numbers to be registered to access CURES (California Health & Safety Code 11165) but does not allow access to student pharmacist. According to California Health & Safety Code 11165, licensees that don’t “prescribe, order, administer, furnish, or dispense controlled substances shall not be provided data obtained from CURES.”

Permitting Pharmacists to delegate PDMP access to licensed Student Pharmacist Interns, can assist in following CDC Guideline for Prescribing Opioid for Chronic Pain, 2016. This guideline recommends that clinicians to review PDMP at the start of opioid therapy and periodically ranging from every prescription to every 3 months. These recommendations are time consuming for clinicians alone and some health institutions have sourced this work to student pharmacist to write the SOAP notes in patient’s EHR under Pharmacist supervision.

Are there any adopted resolutions currently on the books related to this Proposed Resolution? Yes _X__ No___


2008.6 - National Controlled Substances RegistryAPhA-ASP reaffirms APhA-ASP Resolution 2006.2 and furthermore supports the implementation of a national electronic controlled substances registry in an effort to balance the need for patient access to prescription medications for legitimate medical purposes with the need to prevent diversion and abuse. This registry should be accessible by all healthcare professionals.

While this active resolution states that it supports that a national controlled substances registry is recommended and should be accessible by all healthcare professions, not all current state PDMP allow access to student pharmacist.

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Author of Proposed Resolution: Jessica Ocegueda



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R8.17

Proposing APhA-ASP Chapter: University of Southern California

Proposed Resolution Title/Topic: Patient Medication Profile Protocol in Inpatient Pharmacies

Proposed wording: APhA-ASP encourages inpatient pharmacy staff to obtain medication lists when

high-risk patients are hospitalized to ensure patient safety and reduce medication errors.

Inaccurate patient medication profiles often lead to various medication errors, harm to patient safety, and unnecessary health care costs. According to a study published by the British Journal of Clinical Pharmacology, 70% of patients have errors on their medication profiles, 59% of which can cause potentially harmful effects.1 Specifically, in a hospital setting where 20% of admissions are medication-related, there exists an increasing need for an accurate analysis of patients’ medication lists.1 An additional study in the Journal of General Internal Medicine found that one-third of inpatient orders contain errors, 85% of these stemming from the medication history.2 Adverse drug effects caused by inappropriate medication profiles have led to higher costs of health care dude to readmissions (~$12,300 – $13,800) and an increased length of stay by 3.1 days.3

On September 22, 2018, California Governor Jerry Brown signed SB 1254 (Hospital pharmacies: medication profiles or lists for high-risk patients) into law, requiring hospital pharmacies to obtain a medication profile for every high-risk patient upon admission and discharge.4 This law authorizes pharmacists in addition to intern pharmacists and pharmacy technicians, after completion of training, to collect this information from the patient.4

It is important to note that this task was specifically delegated to pharmacy staff, as comparative studies have indicated increased accuracy of medication lists obtained by pharmacy versus this information obtained by other clinical staff.5 Advantages of pharmacy staff carrying this responsibility are not only limited to the initial phase of collecting medication profiles; The Joint Commission Journal on Quality and Patient Safety found that as a result of pharmacy staff completing medication history, there was a 75% reduction in adverse drug effects, cost savings of $830,000, and reduced hospital readmissions.6

By utilizing the inpatient pharmacy staff to obtain and analyze medication profiles upon admission and discharge, there is a high potential for an improvement in health care costs, reduction in medication errors, and increase in patient safety.

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References: 1. Davies EC, Green CF, Mottram DR, et al. Emergency re‐admissions to hospital

due to adverse drug reactions within 1 year of the index admission. Br J Clin Pharmacol. 2010 Nov;70(5):749‐55.

2. Gleason KM, McDaniel MR, FeinglassJ, et al. Results of the medications at transitions and clinical handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med 2010;25:441–7.

3. Hug BL ; Keohane C ; Seger DL; et al. The costs of adverse drug events in community hospitals. Jt Comm J Qual Patient Saf. 2012; 38: 120-126.

4. Jeffrey Stone. California Senate Bill 1254. Hospital pharmacies: medication profiles or lists for high-risk patients. September 22, 2018.

5. Markovic M, Mathis AS, Ghin HL, Gardiner M, . A comparison of medication histories obtained by a pharmacy technician versus nurses in the emergency department. P T. 2017;42(1):41‐46.

6. Gardella JE, Cardwell TB, Nnadi M, Improving medication safety with accurate preadmission medication lists and postdischarge education, Joint Commission J Qual Safety. 2012, 38(10):45288.




Author of Proposed Resolution: Pooja Kumar



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mailto:[email protected]


R8.18

Proposing APhA-ASP Chapter: West Coast University

Proposed Resolution Title/Topic: Limits on Opioid Prescribing

Proposed wording: APhA-ASP supports legislation limiting day supply of initial opioid prescriptions for acute pain, with provisions to allow extended prescriptions for patients with chronic or terminal illnesses to receive appropriate pain management. Extended prescriptions for qualified patients should comply with CDC prescribing guidelines and DEA prescribing limits for scheduled drugs.


Overprescribing opioids contributes to abuse and diversion by increasing the amount of opioids in the general population when these medications are not therapeutically indicated or necessary for pain management. In an analysis conducted by Harvard University, 28.5% of opioids prescribed were not associated with a pain diagnosis.1

Data shows that the probability for long-term use sharply increases in after 5-30 days of initial therapy in first-time opioid patients. The chances of increasing to chronic use is increased after the third day supplied.2

This resolution proposes supporting limiting initial prescriptions for acute pain (e.g., routine dental procedures). Patients who require palliative care for chronic or terminal illnesses, such as cancer, should still have reasonable access to medication determined to be medically necessary to maintain comfortable quality of life.

Pharmacists are still obligated to perform their corresponding responsibility, especially when evaluating if extended prescriptions as described in the resolution are appropriate for the pain management strategy developed by the physician and the patient.

1 Sherry TB, Sabety A, Maestas N. Documented Pain Diagnoses in Adults Prescribed Opioids: Results From the National Ambulatory Medical Care Survey, 2006–2015. Annals of Internal Medicine. September 2018. DOI:10.7326/m18-0644.

2 Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1.

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http://dx.doi.org/10.15585/mmwr.mm6610a1




Author of Proposed Resolution: Alicia O’Connor



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R8.19

Proposing APhA-ASP Chapter: Western University of Health Sciences

Proposed Resolution Title/Topic: MTM Collaboration with other health care providers

Proposed wording: APhA-ASP encourages the recommendation to other health care providers prescribing medications for MTM patients to refer patients with 10 or more medications to a face-to-face or phone interview with their preferred pharmacists or student pharmacists.

Background Statement:Through many years of effort by the pharmacy community, the Medication

Therapy Management (MTM) are starting to become a more applicable tool for improving patient’s overall health. Too many eligible MTM patients however, who can benefit from a face-to-face interview with pharmacists currently either are not utilizing the service or do not even know about the service. Part of the MTM services may include anything from reducing risk of adverse drug effects to even lowering monthly drug costs for patients.

Although there are many studies done in different settings that questions the efficacy of MTM for patients, there are evidence that it has a positive impact on patient adherence, which is one of the most important aspects of maintaining the overall health of patients, especially those that are currently on maintenance medications. It has been shown that over 60% of the population over 65 years old are on at least 5 different medications, and 20% are taking more than at least 10 different medications, leading to an increased risk of adverse drug reaction, hence leading a vicious cycle of more drugs to alleviate the symptoms or more ER visits. If this proposal was adopted with the collaboration of health care professionals from other fields, the pharmacists will have the opportunity to better examine and prevent a potential or occurring adverse reaction, as well as reducing any potential drug duplications that may be a result of patients being seen from different providers. A study was commenced on the success rate of MTM referral in increasing the encounter rate increased significantly from 30.28% to 63.74%, as well as identifying nonadherence from patients and thereby addressing it. This will also increase the awareness for patients who may not be aware that the service is included as part of their healthcare plan, and further encourage them to utilize it whenever they need the service.

Through the collaboration of other healthcare providers who prescribes medications, it will help connect patients and pharmacists in further identifying any

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concerns the patient may have. Inter-professional communication and collaboration has been a long-standing goal by many institutes, and this is the best demonstration of how the collaboration may result in improved overall health of the patients.

References: 1. Imberg AJ, Swanoski MT, Renier CM et.al. Maximizing medication therapy

management services through a referral initiative. AM J Health System Pharmacy. 012 Jul 15;69(14):1234-9. doi: 10.2146/ajhp110511

2. McDonough R. Establishing a referral system for MTM Services. Pharmacy Today. 2012;18:10:31.

3. Bonner L. Physicians refer patients to MTM Pharmacists at Fairview. Pharmacy Today. 2015:21:12:53.

4. Masica AL, Touchette DR, Dolor RJ et.al. Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study Methods. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 4: Technology and Medication Safety). 2008.

5. Mcdonough, R. (2018). Effectiveness of MTM interventions. Pharmacy Today. https://www.pharmacytoday.org/article/S1042-0991(15)30542-9/fulltext [Accessed 30 Sep. 2018].

6. Viswanathan M, Kahwati LC, Golin CE et al. Medication Therapy Management Interventions in Outpatient Settings. Comparative Effectiveness Reviews (No. 138). 2016

7. Benavides S, Madzhidova S, Hernandez A et.al. Establishment of Pediatric Medication Therapy Management: A proposed Model. Pharmacy (Basel). Mar 2016; 4(1):5. Doi: 10.3390/pharmacy4010005



Author of Proposed Resolution: David Liu



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Documents

On September 22, 2018, California Governor Jerry Brown ... R8... · Web viewBerge KH, Dillon KR, Sikkink KM, Taylor TK, Lanier WL. Diversion of Drugs Within Health Care Facilities,